With a 10-day supply of opioids, 1 in 5 become long-term users

But anyway, what's the point of this article and study? It seems like nothing more than more opioid fearmongering.

It seems like this writer, and by extension this publication, is determined to push the anti-opiates message without considering the patients who need them. By all means attack the pharmaceutical companies who mislead people about effectiveness and other awful things, but please cover this from the patients' point of view as well. Cancer is not the only painful condition. Many people need pain relief on a long term basis. It would let people live and work, but instead we get condemnation and refused help.

There's a good solution to the opiod epidemic. TOPICAL, TRANSDERMAL creams compounded by a compounding pharmacy. Topically-applied medications have very little side effects compared to the psychological dependency of ORAL opiates. In addition, you can add different classifications of medications into one cream! You can have an NSAID, anesthetic, etc, all in one cream.

I find it ridiculous that money is at the issue, where an insurance would prefer to pay $5 for someone's addiction rather than $50-200 for a pain cream with little to no side effects and greatly reduced risk of addiction.

There are several places where it is no longer a state crime to possess/distribute marijuana under specific circumstances, but if someone got wrapped up in a federal case I am sure the feds would happily throw in any drug charges they could think of just for fun.

Hmmmm OK he looked at how long people took opiods without looking at why? Apart from removing cancer patients? I mean isn't it more likely that people with a ten day supply have some chronic disease and just continue using it because of that while the one day users are having an accident and don't need it after?

The danger is clearly real but the study sounds worthless

these douchenozzles are saying if anyone takes pain pills more than once then their going to become an addict.

Never tried opioids/hard drugs, can someone tell me what kind of effect it gives you that is so addictive? (Just curious)

You feel like you're sick and going to die if you don't get more immediately. And plus diarrhea. I can't emphasize enough the "immediately" word. There is nothing more important than getting more. Nothing. Not any thing at all. Use your imagination. A lot of things fall under the category of "everything".

Hmmmm OK he looked at how long people took opiods without looking at why? Apart from removing cancer patients? I mean isn't it more likely that people with a ten day supply have some chronic disease and just continue using it because of that while the one day users are having an accident and don't need it after?

The danger is clearly real but the study sounds worthless

these douchenozzles are saying if anyone takes pain pills more than once then their going to become an addict.

That's actually not what they said. They said the chances of being on them a year later were higher. And it's spelled "they're"

Opioid addiction is a real problem, but we should remember how many of today's problems were caused by overreactions to previous problems.

Back in the 70s and 80s, people felt that crime was out of control. The general perception was that the law was too easy on criminals, that there was a revolving door on the justice system, and that the police were powerless or indifferent. The response during the Reagan era was the War on Drugs, three strikes laws, mandatory minimum sentences for drug crimes, and the increased militarization of the police.

In the culture of the 70s and 80s, Dirty Harry was the exception -- treated as a pariah by his own department -- and the SWAT team commander on Hill Street Blues was treated as an object of satire. Now, Dirty Harry cops are common, as well as militarized assaults for even low-level drug crimes.

That's not the only example. In the 70s and 80s, they were plenty of news stories about kids who graduated from high school without being able to read. In an effort to prevent that, we ended up with No Child Left Behind and the proliferation of standardized testing.

The point is that while doctors clearly shouldn't be prescribing unnecessary opioids, we shouldn't make it impossible for people who actually need these painkillers to get them. Doctors shouldn't start by prescribing opioids, but if other painkillers fail to work, they shouldn't be afraid to use them.

In my opinion, denying people in chronic pain from the only medication that works for them would create a situation even worse than what we now face.

There are several places where it is no longer a state crime to possess/distribute marijuana under specific circumstances, but if someone got wrapped up in a federal case I am sure the feds would happily throw in any drug charges they could think of just for fun.

Since it's up to the courts, at this point in time the courts have sided with medical cannabis.

We've known for a while. However, when you tie compensation to patient satisfaction scores, guess what happens. Luckily I work for a department that acknowledged the risks early and created formalized guidelines for narcotic prescriptions. Even having written policy handouts still doesn't prevent me from having to call security at least once a shift to escort out agitated patients who believe they are owed narcotics.

We've known for a while. However, when you tie compensation to patient satisfaction scores, guess what happens. Luckily I work for a department that acknowledged the risks early and created formalized guidelines for narcotic prescriptions. Even having written policy handouts still doesn't prevent me from having to call security at least once a shift to escort out agitated patients who believe they are owed narcotics.

As someone with chronic pain from service connected disabilities that are only going to get worse as I age, I've been taking prescription opiods for nearly 5 years now. As someone with an addictive personality, I was VERY hesitant to take the pain pills at the start.

At first I took the pain pills several times a day as prescribed, which quickly began to take a physical toll on my body in the form of irregular liver function. So I changed things up, after consulting my doctor.

Surprisingly, I have managed to, most of the time, make one month prescriptions last several months by only taking the drugs when I absolutely have to in order to function (usually when my pain level exceeds 7/10). Taking the prescriptions in such small doses for non continuous amounts of time has really helped reduce the side effects. I don't have withdrawls from quitting, the drugs are more effective because my body isn't as immune to them, and my liver function is normal again.

I'd WAY rather use marijuana based drugs if I could do so legally, but I cannot due to our absurd prohibition on pot.

I'm curious how many other sufferers of chronic pain have used opiods like I have, after consulting their doctors, and remain unaddicted. Unless you consider being addicted to not being I'm constantly agony an addiction.

I know it won't work for everyone, but there are other ways to manage chronic pain than turning right to drugs. It's a blessing to have them for when non-narcotic methods don't help, but I wonder how many other sufferers of chronic pain would benefit from exploring non-narcotic ways of testing their pain when possible.

But the authors did note that 10 percent of patients got tramadol, which is considered a relatively safe opioid. So this may hint that some intentional prescriptions for chronic pain is going on.

I hear the withdrawal from tramadol is pretty nasty as well, these also come in a long acting so I'm wondering why it's singled out as it is?

I was treated for an injury some years ago with tramadol and I don't remember having withdrawal symptoms. But I guess reactions are different for everyone.

I developed an addiction to tramadol (I'd been on it for months).

Coming off them was pretty fucking unpleasant, and that was a controlled, gradual withdrawal rather than outright cold turkey.

Whilst still on them, I have a fortnight where I felt like absolute crap, all the time. I went to see the doctor, had blood tests etc, but they couldn't find anything. Then it cleared up, so I got on with my life. A few months later, same thing happens.

The correlation between those two periods was that I was on annual leave, and having a lie-in in the mornings, missing my morning dose as a result. That's when I realised I'd become addicted.

Different people react in different ways, but I'm wary of anyone who describes Tramadol as "safe". It should be treated with the same level of respect and caution as any other Opioid, because you sure as hell don't want to go through the process of having to ease yourself off it.

I'm still in a lot of pain, all the time, but I no longer regularly take prescription meds. I'll take some on days where the pain is too much (whether because I've knocked something, or my tolerance is just low) but otherwise I try to just grin and bear it.

I was only moved onto Tramadol because I asked to be moved off the previous pain relief. There had been a lot of news coverage following research that showed you could develop a codeine dependency after 2 days, and I'd been on max-strength co-codamol for a year. Wasn't addicted to that, but didn't want to risk it. In hind-sight, that was clearly a bad move.

I always thought it was funny that I had a harder time getting antibiotics than I did getting painkillers when I was bedridden (didn't have the strength to walk or crawl) with multiple infections about 5 years ago.

I find it ridiculous that money is at the issue, where an insurance would prefer to pay $5 for someone's addiction rather than $50-200 for a pain cream with little to no side effects and greatly reduced risk of addiction.

What's so surprising about an insurance company not wanting to pay out? They don't give a damn about their customers, as long as they're paying their bills. It's a one way flow of money from us to them unless ABSOLUTELY necessary. It always comes down to the bottom line, and what's best for the patient is rarely the best for profit margins.

Lee: Just for the record, if you kept on taking them, that wonderful feeling would soon vanish, and be replaced with a living hell. Take it from me.

Yup, and that's why I don't keep opiates in the house

Education is part of doing true science. Both of you confirmed that you apparently believe "chasing the high" in that "wonderful feeling" is what opioids pain relief is all about. It is good you do not use them under that impression. Opioid pain relief is just like taking Tylenol or some other nsaid. It handles pain. Pain management is a personal choice.

I would suggest Ars take a more scientific approach to these issues since that seems to be your charter instead of using half baked skewed singular studies that we all know could say whatever the lead wants depending what research ends up staying in the desk and off the report. I suggest reading "Wired" magazines article about the ex gas reseller who is trying to clean up science before trying to pull this stunt again. Lastly I would study the U.S. governments use of "Reefer Madness" to scare people as a herd in a direction they felt was "for the greater good" which is exactly how Ars has been behaving for the most part since you started covering this topic. The irony being you condemn such methods in other application and seem to champion the use of Marijuana.

There is no right or wrong, good or evil in things, it all remains within ourselves. How we use or abuse these things, education, and shared knowledge is how we get to a better place.

Here is some help on how you should inform the public about making better choices. Science facts about how the long term use of opioids on the human body can have serious effects. For example, expect to have energy issues and expect to have your Sphincter of Oddi severed so that you can function normally via ERCP. Constipation is just the tip of the iceberg. You will have to change your diet in extreme ways if you have to use opioids daily. Expect mental changes as well, some good and some bad. Loss of libido long term is a very real risk as well.

Opioids are not easy to live on. They require incredible self discipline. I believe they should be used regularly only in cases that better alternatives aren't an option. Not all opioids are the same, they are all very different in how they affect people, and even the same opioids will affect every person differently. People are not lab rats that will gorge on addictive substances until death, they have a brain. They just need education on how to manage thier illness if opioids are thier best option. If they can't self manage, then other arrangement should be made.

Opioids as a medicine should not be persecuted by those that "chase the high" or aren't educated enough to know "the high" isn't what gives pain relief. You have both disqualified yourselves to have any further valid opinions on the matter. I reccomend you stop using urban overdose hysteria to attack valid medical use any farther just like Reefer Madness was used, and if your decent, you'd even apologize for the damage you've already done.

I've actually created an account for this (but was tempted with the "freeloaders" using electricity so Ars you're slipping)

If the doctor considers the pain to be a long term thing the standard prescribing interval (for an ongoing treatment) is usually a month. However when titrating the dose it's usually 1 bottle (eg "Oramorph, 100ml, 10mg / 5ml") along with a sustained release formulation ("Zomorph 10mg / 12 hours")

Why Morphine? Oxycodone especially (and Fentynl less so) have statistically-significant higher addiction rates than morphine and its long release versions. As does Oxycodone in general (yet weirdly less so for Fentynl in patch form)

Morphine is the front-line drug, if a patient is allergic a fentynl patch is used; oxycodone is rare and really rightfully so.

As a result (dare I say it) the UK doesn't really have a problem with this; there's both easy access and good monitoring of patients (especially at first).

I'd like to present a case study now:

Someone goes in for an operation and initially are prescribed 60mg of codeine as a one-off to treat the pain they've come in complaining of, surgery is scheduled for the next morning, patient is kept pain free in the short term on an "as needed" (not patient controlled) basis.

After surgery they are sent home with a laxative, and say co-codamol (paracetamol 500mg tablet and say codeine 30mg per tablet, 2 tablets at once - there is a 500/15 version (and an 8/500 available over the counter I think)) to last say 2 weeks.

A new pain persists (nerve damage) and they go to see a doctor complaining of significant pain and running out, initially the patient is given 10 days at a time and the doctor will of course require convincing each time.

Eventually both start to work out that it isn't "post-op" pain, and monthly supplies are given out, possibly as separate paracetamol (which the UK uses a lot, it's safe as long as you weigh over 65kg and don't take more than 4g / 24 hours, any more and it becomes REALLY NOT SAFE really quick) and an opiate

Say a year later codeine is starting to loose it's effectiveness so morphine is given, this usually starts as Oramorph 10/5 which is an alcohol formulation, if a user takes a lot of it it will quite literally make them sick. There is a 20/1 formulation without this, Oramorph is prescription only where as the 20/1 is both POM and a controlled drug.

What would this person count as in the study?

This is a "normal" pathway. It'd be irresponsible of the doctor to give 30 days for what is suspected as post-op pain but is also a completely "legitimate" way starting on long term use.

It is worth remembering that only initially is the "nice" part present, with time that goes away and the dose required to get close increases way above the therapeutic dose. The doctor - who both authorises repeat issues and sets the number of repeats (and can even post-date prescriptions) - will notice this; if not at first they will when the "high" dose becomes significantly greater than the therapeutic, this will happen.

It's also worth remembering that codeine and morphine are among the best pain killers we have, and there are few pains which do not respond. Chronic pain is a "catch all" term for a lot of things, some are "mild" to us, some are extreme - it is the doctor's job to weigh up the gains of improving someone's quality of life (by removing the pain) vs the potential of making them an addict.

If they do become addicted their doctor will notice, they may even be told by the patient! I have never seen numbers but I don't imagine these people "magically" "upgrade" to street heroin or something.

So if someone is in life-ruining un-ignorable and unending pain, so what if they get a little bit of joy from the medicine initially, that will fade! Even if they did like it (and it's not their fault for liking it) they're not going to go "best supplement this with heroin now".

Okay so I have addressed the "high" end of the scale and those results are unsurprising, the lower end is tricky, usually 3-10 days of a painkiller at a suitable level for the patient's tolerance is given for "short term" use. For example post-op pain, minor injuries, you know short term stuff.

Usually co-codamol is given here because people in the UK know how deadly paracetamol is and I do think that might play a part in "resisting any temptation" of the codeine component. This usually doesn't require followup and I believe that often (slightly) more than needed is given (however this isn't a bad thing!) which the patient might keep in a cupboard, so what? This stuff is really cheap, it helped their pain, they were given a bit too much, big deal, they're not an addict.

To become an addict they must either go straight to street drugs, or possibly be enabled by a doctor, which we've already discussed.

Now in the US oxycodone is the norm and I cannot stress enough how different to codeine this is, along with hydrocondone (used in Vicadin) and so forth, this is actually a bad thing, these are way more "addictive" than codeine and morphine and there's plenty of evidence backing this up.

If a patient was given oxycodone "to go" (so not PCA) even for 10 days, I would expect there to be a follow up where a withdrawal plan was created and the dose slowly titrated down, for 3 days and it's on the borderline, maybe a follow up; but this might be over-reacting but that's because it is really rare in the UK. I am sure there are guidelines for when to use it.

Really paracetamol, codeine and morphine are our "front-runners" for pain which NSAIDs wouldn't help (eg arthritis, an NSAID will ease both the pain and the cause), with fentinyl playing the part for patients that are allergic.

Here's a fun picture a patient I've dealt with gave me permission to reuse (even like this, because it's to demonstrate how "in stride" they're taking it), it's a bit tongue in cheek but you get the idea:

Those are morphine tablets, and I can tell you it's not an irresponsible quantity for this person and I can also tell you they convinced me that it wasn't a risk to have them in packaging that is essentially for sweets (to put minds at ease) they recognise the rattling sound so would know quickly. I encouraged them to write "morphine" somewhere on there so if the worst did happen they'd have an idea of what the kid took, but given how they taste (apparently) I don't see that being a major risk.

Anyway in closing (TL;DR version):

Opioids and opiates (opioids include synthetic, opiates are natural) are really really useful and I have worked with many people who are on them long term and have a "healthy relationship" with them. However I can only speak for the UK where guidelines are slightly differently.

The "long term" of longer initial doses is completely expected, the 5% for small ones is a little higher (1 in 20) than I expected, however consider the case study!

Really lastly: morphine, codeine, paracetamol are DIRT CHEAP, like you would not believe (check the BNF if you do not believe me) methadone is also really cheap and a doctor and a nurse can oversee MANY recovering addicts along side what they'd be doing anyway so the economical burden is pretty small. Oxycodone isn't, it's about 10x the cost of equivalent morphine dose. "" for the others.

I will respond to questions, I know it's long but I hope SOMEONE reads this!

I have been on every pain killer known to my pain doc (except cannibas, which I am pretty sure works better than anything I've been on after having a 2nd hand smoke experience with it which took both mine and another person's pain away for about a day), even the alternatives that are mentioned in the article. Some of those alternatives had some nasty side effects like constant diarrhea for 24hrs (every 45 min to an hour, I got very dehydrated from that) or other such nasty things. Tramadol was worthless for me (was on it for several months and it never took the pain away). I have a hard time taking Vicodin or Oxy any more after being on them after 3 different surgeries with 18 months. I was taking 12 or so a day along with Valium. A month after the 3rd surgery I gave them up as they did little to nothing for the pain even at that quantity, all it did was make me care a little less about the pain. I drew down to 8 a day and then none within a week. Nasty withdrawal but I did not during that time ever think that I wanted to take some more to ease or get rid of the withdrawal. I had the sweats and insomnia for a week straight along with various other unfun symptoms.

I've been working with a Pain doc for over a year now, and as I said, who has had me try every pain med she could think of. I wound up getting denervation done to help relieve some of the pain, problem was the insurance would not cover it until I had gone through all the meds and several examinations to determine if it "might" help (and even so I am fighting with them about covering it). As of now I am on a pain blocker and a muscle relaxer to help sleep. I can get an opiate/opiod prescription when I want or need it, rarely do. Settled on Morphine as a happy medium between fentanyl and Oxy. I only get small scripts for it when I travel as that causes a lot of pain for me. I don't ever feel the need for more and usually have some left over after a trip and it sits there until the next trip so if I feel I have enough I don't bother to ask for any more (I only get a max of 15 for any trip of at least a week, and this is fine to me).

For me, at least, I don't get a feeling of euphoria from them. Mostly it takes the edge off the pain so I can function or in the case of Vicodin/Oxy, I just care less about the pain. The only ones that I have had that actually took the pain away was fentenyl and cannabis, but I really don't want fentenyl on a regular basis and told the doc as much so we just don't go there. I have pain that will not go away without some very major surgery that insurance won't really cover, multiple disc replacement, so what I am doing now is my option.

Hmmmm OK he looked at how long people took opiods without looking at why? Apart from removing cancer patients? I mean isn't it more likely that people with a ten day supply have some chronic disease and just continue using it because of that while the one day users are having an accident and don't need it after?

The danger is clearly real but the study sounds worthless

Certainly a more detailed study that looked at what the initial prescription was for would be more informative, but why would a doctor write a 5 or 10 day prescription for chronic pain?

Are a large percentage of initial prescriptions for opioids for management of chronic pain? Why strong, initially linear correlation between length of prescription and long term use?

Hmmmm OK he looked at how long people took opiods without looking at why? Apart from removing cancer patients? I mean isn't it more likely that people with a ten day supply have some chronic disease and just continue using it because of that while the one day users are having an accident and don't need it after?

The danger is clearly real but the study sounds worthless

these douchenozzles are saying if anyone takes pain pills more than once then their going to become an addict.

No, they're saying there's a risk, and it increases with number of pills.

Both of you confirmed that you apparently believe "chasing the high" in that "wonderful feeling" is what opioids pain relief is all about. It is good you do not use them under that impression.

Where the hell did you get that impression from? I upvoted you because your reply is a good, factual one, but you are WAAAAAYYYYY off base in your assumption of my post.

Oh, my God, are you way off base.

Please, read what I wrote. I didn't address the issue of pain management at all. In fact, most of my post was about the absolutely DISGUSTING marketing being done by Big Pharma with regards to these drugs. I'm especially disgusted by what RB does with Suboxone.

Again, I am still waiting for someone to give me proof that Dr. Nyswander's theory is correct. I've heard it over and over; countless times, by folks insisting on remaining addicted. It's actually a bit ironic, as they talk about how they have a "permament endorphin/dopamine deficit" (I believe that someone has actually come up with a cute little pseudo-scientific name for it, like "Dopamine Deficit Syndrome" or something like that). They seem to forget they are talking to someone who has been away from the stuff for over thirty years, and is a walking repudiation of their statements.

When the first discs got slipped about 15 years ago (I currently have 4 slipped and one broken and out of place) my doctor forbid me to use painkillers.

She gave me an appointment for dolo-voltaren in injections to be given by a nurse for a couple of weeks. Pain would continue.

When I told them I couldn't live like this, they looked at me and told me that if I had cancer on its final stages they could give me clinical cannabis, but until then all they could do is recommend a few pills every now and then; I got them to give me a box of myolastan under the promise not to abuse it.. and a shrug and smiles when I told them "I was going for cannabis if they couldn't give me anything"

When the last disk decided to part ways (end of 2015) I already knew it probably was a slipped disk and went through the notions as someone already used to be in pain, joints are wonderful for that (after taking a few it doesn't hurt YOU, it hurts HIM, which is good because you are not him so you see the pain in like third person).

Anyway, back to topic, I am addicted to not being in pain, call me weird, and sometimes 3-4 joints are the solution whilst the drugs prescribed by doctors (when they do give you something) are weak and you don't know what would happen if you abuse them.

If people thinks I am weak minded, well, I shall wait til the day when I can give you my body for 24 hours, we'll see how "weak" we all are afterwards.

I find it ridiculous that money is at the issue, where an insurance would prefer to pay $5 for someone's addiction rather than $50-200 for a pain cream with little to no side effects and greatly reduced risk of addiction.

What's so surprising about an insurance company not wanting to pay out? They don't give a damn about their customers, as long as they're paying their bills. It's a one way flow of money from us to them unless ABSOLUTELY necessary. It always comes down to the bottom line, and what's best for the patient is rarely the best for profit margins.

I remember once watching an old black-and-white sitcom (It may have been The Beverly Hillbillies), where a director of an insurance company stated:"The job of an insurance company is to take in as much money as possible, then REFUSE to pay it back."

Or, people in severe need of pain relief has the same need over a long time?

The new CDC recommendations mentioned in the article (to extremely over simplify) are to not prescribe opioids for chronic pain except in cases of cancer, palliative care, or end of life care. People in severe need of pain relief over a long period of time should not be utilizing this type of medication.

What are they supposed to do? See a counselor to talk about their feelings? Deep breathing? A stern talking to from a hospital administrator bobble-head?

Just because it's chronic pain vs. acute doesn't mean it isn't pain.

Some people become junkies after taking pain meds. Does that justify making other responsible people live in pain?

I have been on every pain killer known to my pain doc (except cannibas, which I am pretty sure works better than anything I've been on after having a 2nd hand smoke experience with it which took both mine and another person's pain away for about a day), even the alternatives that are mentioned in the article. Some of those alternatives had some nasty side effects like constant diarrhea for 24hrs (every 45 min to an hour, I got very dehydrated from that) or other such nasty things. Tramadol was worthless for me (was on it for several months and it never took the pain away). I have a hard time taking Vicodin or Oxy any more after being on them after 3 different surgeries with 18 months. I was taking 12 or so a day along with Valium. A month after the 3rd surgery I gave them up as they did little to nothing for the pain even at that quantity, all it did was make me care a little less about the pain. I drew down to 8 a day and then none within a week. Nasty withdrawal but I did not during that time ever think that I wanted to take some more to ease or get rid of the withdrawal. I had the sweats and insomnia for a week straight along with various other unfun symptoms.

I've been working with a Pain doc for over a year now, and as I said, who has had me try every pain med she could think of. I wound up getting denervation done to help relieve some of the pain, problem was the insurance would not cover it until I had gone through all the meds and several examinations to determine if it "might" help (and even so I am fighting with them about covering it). As of now I am on a pain blocker and a muscle relaxer to help sleep. I can get an opiate/opiod prescription when I want or need it, rarely do. Settled on Morphine as a happy medium between fentanyl and Oxy. I only get small scripts for it when I travel as that causes a lot of pain for me. I don't ever feel the need for more and usually have some left over after a trip and it sits there until the next trip so if I feel I have enough I don't bother to ask for any more (I only get a max of 15 for any trip of at least a week, and this is fine to me).

For me, at least, I don't get a feeling of euphoria from them. Mostly it takes the edge off the pain so I can function or in the case of Vicodin/Oxy, I just care less about the pain. The only ones that I have had that actually took the pain away was fentenyl and cannabis, but I really don't want fentenyl on a regular basis and told the doc as much so we just don't go there. I have pain that will not go away without some very major surgery that insurance won't really cover, multiple disc replacement, so what I am doing now is my option.

Even having written policy handouts still doesn't prevent me from having to call security...

(edit: grammar)

It really just blows my mind that you think a "written policy handout" is going to mean anything at all to someone who is either in a lot of pain or addicted to pain meds. These are real people with real issues and you think a cute piece of paper citing some lawyer-ese policy is going to make that better? Only someone who is very much on the spectrum, a robot or a lawyer would be able to think so and sleep at night. But I guess that cute little handout absolves you and the hospital of all responsibility, right?

Don't get me wrong, I've a friend who was an ER doctor and had to deal with junkies all the time, but at least he was more humane and realistic about it than you seem to be.

Kind of reminds me of that line on my mortgage statement saying there's counseling available for those who can't make their payment, except with, you know, pain and addiction and actual humans' lives at stake.

Never tried opioids/hard drugs, can someone tell me what kind of effect it gives you that is so addictive? (Just curious)

For some folks—and I'm one of them, unfortunately—opiates very quickly bring on a feeling of wonderful, poignant, intense euphoria. It's a feeling like being warm, except instead of physical warmth it's an emotional warmth. It's like being softly enfolded in a blanket of feeling like everything is going to work out wonderfully, even if you're actually feeling pretty cruddy about life.

And there's a physical component to it, not just emotional—a humming undercurrent of goodness that attaches itself to and flows through every part of your body. Everything just feels good. You're comfortable no matter what you're doing. If you're actually injured and taking the pills for that injury, the pain is dulled and put into a little box, and you can ignore the box and not look at it if you want. If you're taking the pills and you're not injured, the effect is magnified because you don't have pain to overcome.

Everything is...super interesting, and super exciting. The video game you might be playing is literally the most entrancing, uplifting, fun, vibrant, enjoyable game you've ever played—and while you're playing it, you don't want to ever be doing anything else. The twitter feed you're reading is more fascinating than the best novel you've ever read. The twitch stream you're watching is the most profound, most important thing you've ever seen.

An opiate high makes you feel hopeful, because it makes everything not just interesting, but good. If you've got nothing to look forward to on a Tuesday afternoon except coming home after work/school to a dirty empty house and eating a frozen dinner and playing video games until you fall asleep, an opiate high makes that afternoon into something profound, fun, enjoyable, purposeful, and meaningful. It flows in between the gaps and cracks in what would otherwise be soul-crushing boring routine and fills them in with light and joy and sparkling star-stuff and makes you feel awesome about whatever you're doing.

And, at least for me, after 5 or 6 hours of bliss, the high slowly fades into a beautiful heavy-limbed drowsiness and I can then sleep soundly for 8-10 hours and wake up feeling incredibly refreshed, with a slight echo of the previous day's high.

I am not joking when I say that if I had access to an unlimited supply of opiates, I'd take them every day. Absolutely, 100%. Because they're fucking awesome.

And that terrifies me.

You make it sound so great... I'm glad I have no opiates around right now or I'd consider giving it a try.

My first experience was when I was prescribed Vicodin after I got all four wisdom teeth removed...holy shit did I see when they were addictive. That euphoric and total sublime feeling...you know something is wrong when someone cannot wait to get off work so they can go home and pop some Vicodin pills. Not because they are in pain, but they love the feeling they give you.

After that I said nope to them and totally refuse to take them when offered by doctors.

My family has an alcohol and drug history as it is so I know I'm predisposed to addition problems myself. I consider my coffee habit enough

]Never tried opioids/hard drugs, can someone tell me what kind of effect it gives you that is so addictive? (Just curious)

For some folks—and I'm one of them, unfortunately—opiates very quickly bring on a feeling of wonderful, poignant, intense euphoria. It's a feeling like being warm, except instead of physical warmth it's an emotional warmth. It's like being softly enfolded in a blanket of feeling like everything is going to work out wonderfully, even if you're actually feeling pretty cruddy about life.

And there's a physical component to it, not just emotional—a humming undercurrent of goodness that attaches itself to and flows through every part of your body. Everything just feels good. You're comfortable no matter what you're doing. If you're actually injured and taking the pills for that injury, the pain is dulled and put into a little box, and you can ignore the box and not look at it if you want. If you're taking the pills and you're not injured, the effect is magnified because you don't have pain to overcome.

Everything is...super interesting, and super exciting. The video game you might be playing is literally the most entrancing, uplifting, fun, vibrant, enjoyable game you've ever played—and while you're playing it, you don't want to ever be doing anything else. The twitter feed you're reading is more fascinating than the best novel you've ever read. The twitch stream you're watching is the most profound, most important thing you've ever seen.

An opiate high makes you feel hopeful, because it makes everything not just interesting, but good. If you've got nothing to look forward to on a Tuesday afternoon except coming home after work/school to a dirty empty house and eating a frozen dinner and playing video games until you fall asleep, an opiate high makes that afternoon into something profound, fun, enjoyable, purposeful, and meaningful. It flows in between the gaps and cracks in what would otherwise be soul-crushing boring routine and fills them in with light and joy and sparkling star-stuff and makes you feel awesome about whatever you're doing.

And, at least for me, after 5 or 6 hours of bliss, the high slowly fades into a beautiful heavy-limbed drowsiness and I can then sleep soundly for 8-10 hours and wake up feeling incredibly refreshed, with a slight echo of the previous day's high.

I am not joking when I say that if I had access to an unlimited supply of opiates, I'd take them every day. Absolutely, 100%. Because they're fucking awesome.

And that terrifies me.

My exact experience!

I stay the fuck away because I know I love them.

My step-father actually died from them. Was high on Vicodin and drunk at the same time. His heart stopped. He was supper young too...36. He was an asshole but didn't deserve to die

I've actually created an account for this (but was tempted with the "freeloaders" using electricity so Ars you're slipping)

If the doctor considers the pain to be a long term thing the standard prescribing interval (for an ongoing treatment) is usually a month. However when titrating the dose it's usually 1 bottle (eg "Oramorph, 100ml, 10mg / 5ml") along with a sustained release formulation ("Zomorph 10mg / 12 hours")

[... snipped due to length ...]

JustSomeGuy

I found this to be an interesting read. As a contrast, here is the progression of medications I've been given from my pain clinic that I started seeing in 2009 in the US. I was stated on lortab (hydrocondone 7.5 mg at gift then eventually 10 mg) and was given 90 a month (so 3 / day) and then a few months later I started a new IV medication (Rituxin) that worked off and on and while it worked I stopped taking the pain medication. When the IV medication stopped working completely my condition got worse and I got switched to Percocet (oxycodone 7.5 mg at first, then 10mg) and got switched to a new doctor at the pain clinic. She gave me 30 MS Contin (morphine extended release 15 mg) in addition to the 90 Percocet a month.

We eventually found another IV medication (abatacept) that, while it didn't work well as the Rituxin, it gave me some relief and made it so I could work regularly (I was on intermittent FMLA leave and working from home tons.) I couldn't ever go of three pain medications completely since this IV medication didn't work as well, but I could take what was a one month supply and make it last 2 or 3 months. Around the end of 2014 or beginning of 2015 it started wearing off slowly and the pain came back. As the pain got worse I started needing refills every month again and they ended up also giving me 15 Dilaudid for flare-ups (first tried 1mg, but that wasn't quite enough so we went to 2mg).

In November 2015 the IV medication was ineffective enough that my doctor had me stop it and we've been trying new medications and chemo since then, but so far nothing has worked. Early 2016 my pain doctor quit and I started seeing a new doctor in the same practice. She wanted me to take more of the long acting medications and so I started getting 60 MS Contin a month and went from 90 Percocet a month to 60. As my pain and flare-ups have gotten worse she also increased my MS Contin to 30 mg my Dilaudid to 4 mg.

As my condition has gotten worse and I've ended up needing to go to the ER due to pain and for IV steroids (even if the pain is under control the flare-up will last for until I get a large dose of IV steroids, usually 125 mg solumedrol or occasionally 16 mg decadron. I have an order for IV steroids at the IV clinic, but most of my flare-ups start after 5 pm when they close, so I try to wait for the next day, but often end up in the ER). Since I've gotten worse the pain clinic switched my MS Contin to Oxymorphone Extended Release 7.5 mg and then last month they increased it to 10 mg.

They've also tried several other non narcotic medications, like Neurontin, Cymbalta, Zonegran, etc. They also tried some sphenopalatine ganglion nerve blocks to see if they'd help, but it just caused a decrease in the headaches that accompany a flare-up, but not the face and neck pain.

You also commented that Oxycodone wasn't as cheap, but it's fairly cheap after my insurance for me. All of the pain medications I've tried have been $10 / month after insurance (at least until I got my max out of pocket, which I do every year), which is as cheap as medication gets on my insurance, which isn't​ all that great (it's a fairly expensive high deductible ($3k deductible, $6k max out of pocket) plan, so not the worst out there, but the worst I've had, especially given the premiums.)

Or, people in severe need of pain relief has the same need over a long time?

The new CDC recommendations mentioned in the article (to extremely over simplify) are to not prescribe opioids for chronic pain except in cases of cancer, palliative care, or end of life care. People in severe need of pain relief over a long period of time should not be utilizing this type of medication.

What are they supposed to do? See a counselor to talk about their feelings? Deep breathing? A stern talking to from a hospital administrator bobble-head?

Just because it's chronic pain vs. acute doesn't mean it isn't pain.

Some people become junkies after taking pain meds. Does that justify making other responsible people live in pain?

I agree. It would kind of be like if car manufacturers added a feature to help save lives of the people who decided not to wear seatbelts, but it increased the danger and likelihood of death to people who wear seatbelts. How many people would want to buy a car with that feature? I realize this isn't a perfect analogy as addiction isn't always a choice, like choosing to not wear a seatbelt always is, but I think it still makes the point.

The problem is many people don't know what it's like to live with severe chronic pain, day in and day out, with no end in sight (although they may think they do) and so they have little to no sympathy for it or don't care about it at all.

Or, people in severe need of pain relief has the same need over a long time?

The new CDC recommendations mentioned in the article (to extremely over simplify) are to not prescribe opioids for chronic pain except in cases of cancer, palliative care, or end of life care. People in severe need of pain relief over a long period of time should not be utilizing this type of medication.

What are they supposed to do? See a counselor to talk about their feelings? Deep breathing? A stern talking to from a hospital administrator bobble-head?

Just because it's chronic pain vs. acute doesn't mean it isn't pain.

Some people become junkies after taking pain meds. Does that justify making other responsible people live in pain?

I agree. It would kind of be like if car manufacturers added a feature to help save lives of the people who decided not to wear seatbelts, but it increased the danger and likelihood of death to people who wear seatbelts. How many people would want to buy a car with that feature? I realize this isn't a perfect analogy as addiction isn't always a choice, like choosing to not wear a seatbelt always is, but I think it still makes the point.

The problem is many people don't know what it's like to live with severe chronic pain, day in and day out, with no end in sight (although they may think they do) and so they have little to no sympathy for it or don't care about it at all.

The root of much misunderstanding, conflict and worse has a lot to do with some peoples' absence of empathy.

I've actually created an account for this (but was tempted with the "freeloaders" using electricity so Ars you're slipping)

If the doctor considers the pain to be a long term thing the standard prescribing interval (for an ongoing treatment) is usually a month. However when titrating the dose it's usually 1 bottle (eg "Oramorph, 100ml, 10mg / 5ml") along with a sustained release formulation ("Zomorph 10mg / 12 hours")

Why Morphine? Oxycodone especially (and Fentynl less so) have statistically-significant higher addiction rates than morphine and its long release versions. As does Oxycodone in general (yet weirdly less so for Fentynl in patch form)

Morphine is the front-line drug, if a patient is allergic a fentynl patch is used; oxycodone is rare and really rightfully so.

As a result (dare I say it) the UK doesn't really have a problem with this; there's both easy access and good monitoring of patients (especially at first).

I'd like to present a case study now:

Someone goes in for an operation and initially are prescribed 60mg of codeine as a one-off to treat the pain they've come in complaining of, surgery is scheduled for the next morning, patient is kept pain free in the short term on an "as needed" (not patient controlled) basis.

After surgery they are sent home with a laxative, and say co-codamol (paracetamol 500mg tablet and say codeine 30mg per tablet, 2 tablets at once - there is a 500/15 version (and an 8/500 available over the counter I think)) to last say 2 weeks.

A new pain persists (nerve damage) and they go to see a doctor complaining of significant pain and running out, initially the patient is given 10 days at a time and the doctor will of course require convincing each time.

Eventually both start to work out that it isn't "post-op" pain, and monthly supplies are given out, possibly as separate paracetamol (which the UK uses a lot, it's safe as long as you weigh over 65kg and don't take more than 4g / 24 hours, any more and it becomes REALLY NOT SAFE really quick) and an opiate

Say a year later codeine is starting to loose it's effectiveness so morphine is given, this usually starts as Oramorph 10/5 which is an alcohol formulation, if a user takes a lot of it it will quite literally make them sick. There is a 20/1 formulation without this, Oramorph is prescription only where as the 20/1 is both POM and a controlled drug.

What would this person count as in the study?

This is a "normal" pathway. It'd be irresponsible of the doctor to give 30 days for what is suspected as post-op pain but is also a completely "legitimate" way starting on long term use.

It is worth remembering that only initially is the "nice" part present, with time that goes away and the dose required to get close increases way above the therapeutic dose. The doctor - who both authorises repeat issues and sets the number of repeats (and can even post-date prescriptions) - will notice this; if not at first they will when the "high" dose becomes significantly greater than the therapeutic, this will happen.

It's also worth remembering that codeine and morphine are among the best pain killers we have, and there are few pains which do not respond. Chronic pain is a "catch all" term for a lot of things, some are "mild" to us, some are extreme - it is the doctor's job to weigh up the gains of improving someone's quality of life (by removing the pain) vs the potential of making them an addict.

If they do become addicted their doctor will notice, they may even be told by the patient! I have never seen numbers but I don't imagine these people "magically" "upgrade" to street heroin or something.

So if someone is in life-ruining un-ignorable and unending pain, so what if they get a little bit of joy from the medicine initially, that will fade! Even if they did like it (and it's not their fault for liking it) they're not going to go "best supplement this with heroin now".

Okay so I have addressed the "high" end of the scale and those results are unsurprising, the lower end is tricky, usually 3-10 days of a painkiller at a suitable level for the patient's tolerance is given for "short term" use. For example post-op pain, minor injuries, you know short term stuff.

Usually co-codamol is given here because people in the UK know how deadly paracetamol is and I do think that might play a part in "resisting any temptation" of the codeine component. This usually doesn't require followup and I believe that often (slightly) more than needed is given (however this isn't a bad thing!) which the patient might keep in a cupboard, so what? This stuff is really cheap, it helped their pain, they were given a bit too much, big deal, they're not an addict.

To become an addict they must either go straight to street drugs, or possibly be enabled by a doctor, which we've already discussed.

Now in the US oxycodone is the norm and I cannot stress enough how different to codeine this is, along with hydrocondone (used in Vicadin) and so forth, this is actually a bad thing, these are way more "addictive" than codeine and morphine and there's plenty of evidence backing this up.

If a patient was given oxycodone "to go" (so not PCA) even for 10 days, I would expect there to be a follow up where a withdrawal plan was created and the dose slowly titrated down, for 3 days and it's on the borderline, maybe a follow up; but this might be over-reacting but that's because it is really rare in the UK. I am sure there are guidelines for when to use it.

Really paracetamol, codeine and morphine are our "front-runners" for pain which NSAIDs wouldn't help (eg arthritis, an NSAID will ease both the pain and the cause), with fentinyl playing the part for patients that are allergic.

Here's a fun picture a patient I've dealt with gave me permission to reuse (even like this, because it's to demonstrate how "in stride" they're taking it), it's a bit tongue in cheek but you get the idea:

Those are morphine tablets, and I can tell you it's not an irresponsible quantity for this person and I can also tell you they convinced me that it wasn't a risk to have them in packaging that is essentially for sweets (to put minds at ease) they recognise the rattling sound so would know quickly. I encouraged them to write "morphine" somewhere on there so if the worst did happen they'd have an idea of what the kid took, but given how they taste (apparently) I don't see that being a major risk.

Anyway in closing (TL;DR version):

Opioids and opiates (opioids include synthetic, opiates are natural) are really really useful and I have worked with many people who are on them long term and have a "healthy relationship" with them. However I can only speak for the UK where guidelines are slightly differently.

The "long term" of longer initial doses is completely expected, the 5% for small ones is a little higher (1 in 20) than I expected, however consider the case study!

Really lastly: morphine, codeine, paracetamol are DIRT CHEAP, like you would not believe (check the BNF if you do not believe me) methadone is also really cheap and a doctor and a nurse can oversee MANY recovering addicts along side what they'd be doing anyway so the economical burden is pretty small. Oxycodone isn't, it's about 10x the cost of equivalent morphine dose. "" for the others.

I will respond to questions, I know it's long but I hope SOMEONE reads this!

JustSomeGuy

Since you are from the UK, here's some trivia and a question.

The US represents about ~80% of the worldwide opioid prescriptions.Canada + Western Europe represent about ~15%.Americans are being prescribed opioids far more frequently than British or other Western Europeans, with a similar lifestyle and wealth.

Question:Are the UK doctors forcing avoidable pain on their patients by being too cautious on prescribing opioids?Or are US doctors exposing their patients to avoidable addiction risk by relying too much on opiods for pain management?

What are the "safe" limits for prescribing opioids to a patient without regular control tests? How regular should those controls be?

The problem statement is relatively simple:Americans are being prescribed opiods on a far more frequent basis than other comparable countries.Some are getting addicted. And some are dying of overdose.And there's a huge lack of facts on the matter.Opiods seem to be far more addictive than previously thought; some of the common synthetics were at some point marketed as having low addiction risk.

This article reports on a first study which attempts to shed a tiny bit of light on the matter, by using 1-year usage as proxy for addiction.The article acknowledges that some of the 1-year users are suffering from chronic pain and does not quantify it; but it argues it's probably a small part of the study population.

How does JustSomeGuy's study case fit?It's just one case, which can perfectly fit in the 1-10% guesstimate of chronic pain prescriptions from the study authors.